Based on data from the literature, we have developed a computer-based simulation model to compare the long-term effectiveness of different preventive strategies of osteoporotic fractures. The Markov model comprises 25 states, including states which describe women distributed according to three levels of fracture risk, fractures states, post-fracture states and a death state. We chose eight standard preventive strategies, which we compare with the ‘No Treatment’ reference strategy. The first two strategies consist in treating all 50-year-old women for 5 or 10 years with hormone replacement therapy (HRT). Strategies 3 and 4 aim at assessing a 5-year course of treatment with bisphosphonates in osteopenic and osteoporotic 65- or 75-year-old women. Strategies 5 and 6 combine 5 years of HRT in all 50-year-old women with 5 years of bisphosphonates in osteopenic and osteoporotic women at 65 or 75 years. The last two strategies simulate 10 years of HRT in all 50-year-old women, followed by strategy 3 or strategy 4. Simulated life expectancy and mean ages of fracture occurrence fit well with the observed data. All the preventive strategies tested reduced the number of fractures. Early 10-year HRT in all women, plus 5 years of bisphosphonates in women at risk of fractures at 65 or 75 years, are the most effective strategies, with an 18.4–19.0% reduction in all fractures, and a 25.6–26.1% reduction in the number of hip fractures. Strategy 2 has a similar outcome, thus demonstrating the value of treatment started early and sustained over a long period. The strategies implemented later, S3 and S4, only concern women at risk (i.e., osteopenic or osteoporotic), and are less effective, with a 1.5–2.1% decrease in all fractures. The combined strategies, S5 and S6, produce intermediate results: a 12.9–13.5% reduction in the number of all fractures and a 17.5–17.9% reduction in hip fractures.

BACKGROUND:During these last years, many structured and standardized diagnostic interviews have been developed in order to identify psychiatric disorders in a standardized way. These tools enable a systematic investigation of these disorders according to international classifications. Their main drawback is to be long. To assess the care of depression, we used a shorter and more simple tool: the Mini International Neuropsychiatric Interview (MINI) to identify depressive subjects.METHOD:The study was conducted in the Gazel cohort from the French National Electricity and Gas Company. A stratified sample of 2394 civil servants selected in order to over-represent depressive subjects was asked to answer to the MINI interview through a phone interview. An epidemiological and statistical analysis was performed to test the MINI internal validity: prevalence of depressive disorders using different threshold of diagnosis (number of symptoms required to identify someone as depressive), frequency of different symptoms, variability between investigators and potential biases.RESULTS:Respondents to the phone interview (1108 civil servants) had more often presented depression markers for the last 5 years. Prevalence of depressive episodes changed little when we varied the threshold of diagnosis and did not stress any threshold problem. The variability between investigators was important, but the estimation of prevalence remained stable when we excluded extreme rates of prevalence. The choice of a classification system affected the prevalence estimation. Using the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) from the American Psychiatric Association, the prevalence of depressive episodes was lower and closer to the estimations shown in the literature than using the International Classification of Disease (ICD 10). Moreover, the stratification assigned very unbalanced weights to the stratification strata. By excluding depressive episodes observed in the stratum "control" (no depression "marker" from 1989 to 1994 in the database), the prevalence was very lower, whatever the classification was. Finally, factors which appeared linked to care of depression with the ICD definition remained the same when the DSM diagnosis definition was used, and relative risks were quite similar.CONCLUSION:The MINI appears to be a short and simple tool, suited to the epidemiological studies. This analysis does not highlight any failure in the internal consistency of the MINI. The remaining question is what the MINI really measures, particularly comparing to a psychiatrist's diagnosis.

UNLABELLED:The notion of stabilization in schizophrenia has been investigated, in France, through a survey of 875 psychiatrists. This survey, which has been conducted on the 9th, 10th and 11th of December 1997, looked into the clinical, therapeutic and socio-demographic variables, and the means of patient management, which are used by psychiatrists to ascertain that their patients are stabilized. The data was collected by each psychiatrist by way of a questionnaire administered to his or her next three patients, either at the hospital or in private practice (2,464 questionnaires were completed). RESULTS:65% of the patients seen during this survey were considered stabilized by their psychiatrist (n = 1,597). The most common clinical presentation was of the paranoïd type. An insiduous onset of disease seems to be correlated with an absence of stabilization. Stabilization appears to be estimated at a given time rather than over a time period, since over half the patients who were considered stabilized had suffered at least one relapse over the last 2 years, and had been rehospitalized an average of 2.4 times over that period. In terms of drug therapy, they received 1.4 neuroleptic drugs, which does not differ markedly from the 1.5 neuroleptics administered to patients who were considered non stabilized. Co-prescriptions of anticholinergic medications, benzodiazepines and antidepressants were very common in these patients considered stabilized (49.9%, 39.8% and 24.8% respectively), which is similar to that observed in their non-stabilized counterparts (47.6%, 45%, 8% and 26.4%, respectively). Patient follow-up remained above an average of 1 patient visit per month (an average of 8.9 visit over the last 6 months), despite the fact that patients were considered stabilized. Two primary criteria were used by psychiatrists to determine that a patient was stabilized: treatment compliance and the absence of positive symptoms. However, 43% of the patients which were considered stabilized still presented with positive symptoms. Negative symptoms were also very prevalent in these patients (65%), as well as concomitant depressive signs (36%) and anxiety (64%). CONCLUSION:Even though the concept of stabilization remains difficult to define, it appears that schizophrenic patients are considered by their psychiatrist as stabilized on the grounds of good treatment compliance and decreased positive symptoms. Therefore, even in these so-called stabilized patients, enhancements are still possible, as symptoms remain present.

INTRODUCTION:The use of antidepressants has been questioned with respect to both undertreatment and inadequate prescription. The present investigation was therefore launched to assess the psychopathology profiles of antidepressant users.METHODS:A representative sample was constituted on the basis of usual antidepressant consumption, and ICD 10 compatible diagnoses were obtained after telephone administration of a structured psychiatric interview.RESULTS:The most often used drugs were fluoxetine, followed by tricyclic antidepressants. Coprescription existed in slightly less than two thirds of antidepressant users. ICD 10 diagnoses were compared to currently available prescription guidelines. Fluoxetine prescription, as compared to other drugs, was found to be significantly more compliant with these guidelines; conversely, in 22% of antidepressant users, no complete ICD 10 diagnosis could be documented. These results are discussed in the light of report accuracy and anecdotal or 'heterodox' indications of antidepressants.CONCLUSION:Altogether, the present study confirms previous doubts regarding appropriate use of antidepressants and stresses the need for more explicit and comprehensive clinical guidelines. It does not substantiate, however, any evidence for a 'recreational' use of these products.

The notion of stabilization in schizophrenia has been investigated, in France, through a survey of 875 psychiatrists. This survey which has Seen conducted on the 9th, 10th and 11th of december 1997 looked into the clinical, therapeutic and socio-demographic variables, and the means of patient management, which are used by psychiatrists to ascertain that their patients are stabilized. The data was collected by each psychiatrist by way of a questionnaire administered to his or her next three patients, either at the hospital or in private practice (2464 questionnaires were completed). Results : 65 % of the patients seen during this survey were considered stabilized by their psychiatrist (n = 1 597). The most common clinical presentation was of the paranoid type. An insiduous onset of disease seems to be correlated with an absence of stabilization. Stabilization appears to be estimated at a given time rather than over a time period, since over half the patients who were considered stabilized had suffered at least one relapse over the last 2 years, and had been rehospitalized an average of 2.4 times over that period. In terms of drug therapy, they received 1.4 neuroleptic drugs, which does not differ markedly from the 1.5 neuroleptics administered to patients who were considered non stabilized Go-prescriptions of anticholinergic medications, benzodiazepines and antidepressants were very common in these patients considered stabilized (49,9 %, 39,8 % and 24,8 % respectively), which is similar to that observed in their non-stabilized counterparts (47,6 %, 45 %, 8 % and 26,4 %, respectively). Patient follow-up remained above an average of 1 patient visit per month (an average of 8.9 visits over the last 6 months), despite the fact that patients were considered stabilized Two primary criteria were used by psychiatrists to determine that a patient was stabilized : treatment compliance and the absence of positive symptoms. However, 43 % of the patients which were considered stabilized still presented with positive symptoms. Negative symptoms were also very prevalent in these patients (65 %), as well as concomitant depressive signs (36 %) and anxiety (64 %). Conclusion: Eventhough the concept of stabilization remains difficult lo define, ii appears that schizophrenic patients are considered by their psychiatrist as stabilized on the grounds of good treatment compliance and decreased positive symptoms. Therefore, even in these so-called stabilized patients, enhancements are still possible, as symptoms remain present.

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Le but de cette etude est d'evaluer comment les antidepresseurs sont prescrits et qui en beneficie. Elle comporte une premiere phase (enquete en population generale) afin de selectionner, par questionnaire postal, un echantillon representatif des utilisateurs d'antidepresseurs, sans passer par le prescripteur, pour eviter le biais qu'il peut representer. Ses resultats indiquent une prevalence ponctuelle d'utilisation des 8 principaux antidepresseurs egale a 2,75%, soit plus d'un million d'adultes en France. La distribution des antidepresseurs place en tete le Prozac® suivi de l'Anafranil® et du Laroxyl®. Viennent ensuite le Stablon®, l'Athymil®, le Survector® et le Ludiomil®. Dans plus de 50 % des cas, les antidepresseurs sont consommes, depuis un an ou plus, de facon continue ou discontinue. Ils sont prescrits par le generaliste dans 60 % des cas et par le psychiatre dans 30 % des cas. Une seconde phase d'enquete (telephonique), menee par des medecins psychiatres aupres d'un echantillon de cette population, a permis de determiner le profil psychopathologique des consommateurs au moment de la prescription du traitement antidepresseur a l'aide d'un outil diagnostique valide, le MINI. Ses resultats indiquent, tous traitements confondus, une prescription dans le cadre de l'AMM dans environ 65 % des cas (presence d'un episode depressif 61 %, dysthymie 3 %, TOC 1%). Cette etude montre que dans 23 % des cas les antidepresseurs ne sont pas utilises chez des sujets ayant un des diagnostics psychiatriques identifie par le MINI mais souffrant neanmoins de symptomes psychopathologiques (subsyndromique syndrome). Si on peut donc en conclure que les antidepresseurs sont utilises dans des troubles non caracterises, chez certains sujets, on doit aussi reconnaitre qu'avec 3 % de consommateurs, la population de sujets traites par antidepresseur est inferieure a celle des patients souffrant, en population generale, de depression (5 a 10 % par an selon les etudes).

The objective of this study was to evaluate the mode of prescription and the users of antidepressant agents. It consisted of an initial phase (survey of the general population), aimed at selecting a representative sample of antidepressants users by a mail questionnaire, without asking prescribers in order to avoid the bias inherent to such an approach. Results showed a current incidence of use of 2.75 % for the 8 main antidepressants, i.e. more than one million adults in France. The distribution of antidepressants showed Prozac in first place, followed by Anafranil, and Laroxyl, then Stablon, Athymil, Survector and Ludiomil. In more than 50 % of cases, antidepressants have been taken for a year or more, continuously of intermittently. They were prescribed by a general practitioner in 60 % of cases and a psychiatrist in 30 %. A second survey phase (telephone) undertaken by psychiatrists and involving a sample of this population enabled determination of the pathophysiological profile of consumers at the time of prescription of antidepressant treatment, using a validated diagnostic tool, the MINI. Taking all drugs together, results showed that prescription was within Marketing Authorization approved indications in about 65 % of cases (existence of depression 61 %, dysthymia 3 %, OCD 1 %). This study shows that, in 23 % of cases, antidepressants are not used in patients with one of the psychiatric diseases identified by the MINI but nevertheless suffering from pathophysiological symptoms (subsyndronic syndrome). It can be concluded that, in some subjects, antidepressants are used in non-identified disorders. It must also be recognized that, with 3 % of users, the population of individuals treated by antidepressants is less than that of patients suffering, in the general population, from depression (5 to 10 % per year, according to studies).

The objective of this study was to evaluate the mode of prescription and the users of antidepressant agents. It consisted of an initial phase (survey of the general population), aimed at selecting a representative sample of antidepressants users by a mail questionnaire, without asking prescribers in order to avoid the bias inherent to such an approach. Results showed a current incidence of use of 2.75 % for the 8 main antidepressants, ie. more than one million adults in France. The distribution of antidepressants showed Prozac(R) in first place, followed by Anafranil(R) and Laroxyl(R), then Stablon(R), Athymil(R), Survecfor(R) and Ludiomil(R). In more than 50 % of cases, antidepressants have been taken for a year or more, continuously of intermittently. They were prescribed by a general practitioner in 60 % of cases and a psychiatrist in 30 %. A second survey phase (telephone) undertaken by psychiatrists and involving a sample of this population enabled determination of the pathophysiological profile of consumers at the time of prescription of antidepressant treatment, using a validated diagnostic tool, the MINI. Taking all drugs together, results showed that prescription was within Marketing Authorization approved indications in about 65 % of cases (existence of depression 61 %, dysthymia 3 %, OCD 1 %). This study shows that, in 23 % of cases, antidepressants are not used in patients with one of the psychiatric diseases identified by the MINI but nevertheless suffering from pathophysiological symptoms (subsyndronic syndrome). It can be concluded that, in some subjects, antidepressants are used in non-identified disorders. If must also be recognized that, with 3 % of users, the population of individuals treated by antidepressants is less than that of patients suffering, in the general population, from depression (5 to 10 % per year, according to studies).